Inspection on 12/12/05 for Cherrytrees

This inspection was carried out on 12th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 23 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cherrytrees 30/01/09

Cherrytrees 23/05/07

Cherrytrees 08/06/06

Cherrytrees 31/05/05

Cherrytrees 25/10/04

Cherrytrees 18/05/04

Cherrytrees 05/12/03

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Cherrytrees Cherrytrees Kitelands Road Biggleswade Bedfordshire SG18 8NX Lead Inspector Rachel Geary Unannounced Inspection 12th December 2005 16:25 Cherrytrees DS0000033114.V272486.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cherrytrees DS0000033114.V272486.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cherrytrees DS0000033114.V272486.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cherrytrees Address Cherrytrees Kitelands Road Biggleswade Bedfordshire SG18 8NX 01767 313370 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Bedfordshire County Council Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Cherrytrees DS0000033114.V272486.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. No of residents: 2 Gender: Male and female Category: Learning disability Period of stay: Respite (max 6 weeks stay) Service users over 65 years. Current respite service users who are over 65 years of age may continue to receive a service from the home, as long as their needs are being met. No new service users over 65 years of age may be admitted to the home without prior consultation with the NCSC/CSCI. An application for the position of manager with sole responsibility for the respite service must be received by 31/3/04. Re-provision. Complete re-provision (subject to CSCI and other relevant authorities approval of the proposed plans) of the respite service by November 2005. 31st May 2005 6. 7. Date of last inspection Brief Description of the Service: Cherrytrees is a respite service located on the outskirts of Biggleswade, sharing a site with a domiciliary care service. The accommodation and grounds are owned and maintained by Aldwyck Housing Association, with Bedfordshire County Council providing the staffing and care support. The service currently has a condition of registration to reprovide by November 2005 as it does not meet the environmental requirements of the National Minimum Standards for Younger Adults. It is hoped that the service will remain in the local area. At the time of writing, there were no known timescales for this to happen. The accommodation comprises of a small flat, which is intended to provide respite care for up to 2 adults with learning disabilities at any one time. Stays are limited to a maximum of six weeks. There are two bedrooms, a shared kitchen, a bathroom and a living/dining area. The accommodation would not meet the needs of individuals with a physical disability. Community facilities and shops are a short distance from the home, which is also in easy access of local transport routes. Cherrytrees DS0000033114.V272486.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced, and took place from 16.25 to 20.00. The inspector met service users, spoke to the member of staff on duty, observed practice, looked at records, and had a partial tour of the premises. After the inspection, feedback was provided to the resource manager for this service. A written response had been received by the time of writing, and where relevant, this information has been included in this report. The CSCI is in the process of amending the home’s conditions of registration. This because some of them are now out of date. It was noted that the current certificate of registration was not on display. This is a legal requirement. Records indicated that there were over 20 service users using this respite service on a regular basis. What the service does well: What has improved since the last inspection? What they could do better: There are a number of things that the home could do to improve the service that is provided. Care plans and related paperwork need further work to provide sufficient information for staff to meet the holistic needs of service users, and to demonstrate that service users’ assessed needs are being met. In addition, there should be more opportunities for service users to develop their individual skills, and to enjoy experiences associated with every day living. Some of the current practices do not promote the autonomy and independence of the service users from the respite or adjacent supported living unit. Cherrytrees DS0000033114.V272486.R01.S.doc Version 5.0 Page 6 Finally, the service must address the significant number of outstanding inspection requirements, and continue to develop paperwork and systems for staff and service users, to make sure that they are meeting legal requirements, and the Government’s standards for services such as Cherrytrees respite service. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Cherrytrees DS0000033114.V272486.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cherrytrees DS0000033114.V272486.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5. Some useful documentation is available to help prospective service users and their families to be clear about the service being provided at Cherrytrees. However, there is evidence to suggest that the home is failing to meet the holistic needs and aspirations of the people using this service. EVIDENCE: The Statement of Purpose and Service User Guide were on display in the entrance hall. Both documents were illustrated with pictures to help service users to understand them, and contained the majority of required information. However, as previously reported, some information was inaccurate or missing. The Statement of Purpose had not been updated since the last inspection, so was not examined on this occasion. Information regarding the home’s assessment procedure was included in the Statement of Purpose. However, no assessment information was found on file for one new service user. This standard could not therefore, be assessed in full on this occasion. The resource manager confirmed afterwards that this work had been completed, but this was not verified on this occasion. An exception to the home’s conditions of registration had been made for one service user who had been staying at Cherrytrees since September. This was because of unusual circumstances, and it was planned that the person in question would move into a permanent placement by January. There was evidence that the service was only meeting the service user’s basic needs. For Cherrytrees DS0000033114.V272486.R01.S.doc Version 5.0 Page 9 example, the care plan contained limited up to date information regarding the individual’s present circumstances, and their holistic needs. See also the ‘personal and healthcare support’ and ‘lifestyle’ sections of this report. A blank Service User Contract/Terms and Conditions was on display in the entrance foyer. Good attempts had been made to ensure this document contained the required information and was user friendly however, there was evidence that this had been copied from another similar service, and therefore required updating to include information specific to the service at Cherrytrees. Completed contracts were not found on either of the service user’s files examined on this occasion. Cherrytrees DS0000033114.V272486.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Care plans and risk assessments do not adequately enable staff to meet service users’ holistic needs and aspirations. Neither do they promote opportunities for service users to develop their independent living skills. EVIDENCE: As previously reported, service user files had been organised into categories with daily notes also being maintained. Examination of files showed that the content of care plans differed with some being more comprehensive than others. Important information was also missing or lacked clarity. One example of this was the guidelines for supporting one service user who was not drinking sufficiently, and who also had diabetes. Records indicated that she liked hot drinks with sweeteners, yet her care plan did not include this information. As a result, the member of staff felt unable to give the person in question a drink with a sweetener. A straw was provided, and it was explained that this made it easier for the person to drink. Again, this information had not been included in the plan of care. A care plan for one new service user contained basic information, and a spelling error with regard to the person’s forename. This care plan had been signed by the parent of the service user and included the type written line ‘the Cherrytrees DS0000033114.V272486.R01.S.doc Version 5.0 Page 11 care plan agreed to by us is very much to our liking. It is comprehensive and detailed’. The resource manager stated that the spelling error had been corrected immediately after the inspection. Plans did not include personal goals or make clear links to outcomes from the most recent review. In one case, the last review notes on file were dated 1999. In addition, there was no evidence that the service user and/or their family/representatives had contributed to another plan, and there was limited information about important people such as siblings. The plan was also not user friendly or dated. As reported in other sections of this report, the home had developed a number of systems to help service users to be able to understand information provided by the home, and to be able to make certain decisions. As previously reported, a number of generic risk assessments had been completed however; limited individual risk assessments were in place specifically those required to promote independent living opportunities. Information on one person’s care plan stated that full support was required in all areas, but it was not clear why. There were no risk assessments in place for one new service user. Cherrytrees DS0000033114.V272486.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14 and 16. There is limited evidence that service users have regular access to a variety of meaningful activities. EVIDENCE: Cherrytrees DS0000033114.V272486.R01.S.doc Version 5.0 Page 13 As previously reported, the home had adopted a system called ‘planning your stay with us’. It was intended that a user-friendly chart be completed with each service user on arrival at the unit, covering their preferences with regard to leisure activities and working on independent living skills. In addition, a photo activity chart to record individual’s likes and dislikes had been developed. There was little evidence however, of either system being used on a regular basis. No external activities had been planned during this inspection. Both service users spent time watching TV, or listening to music (on one occasion at the same time and in the same room). One service user was encouraged to participate in preparing the evening meal and laying the table, and after tea, it was noted that the member of staff tried to engage the service users in some indoor activities/games. Records indicated that service users were not accessing community facilities and external activities on a regular basis. This included one service user who was staying at the unit for approximately 4 months. One entry in the staff communication book read ‘ I failed to take (one service user) out this pm as I booked a taxi, but when it came it was hijacked by the main unit, for their clients’. There was evidence that this deficit had been noted by the manager, and that she was attempting to address it. See also ‘concerns and complaints’ section of this report. The member of staff on duty was observed interacting appropriately with the services users, and providing support at a pace that appeared to reflect the needs of each individual. As previously reported, the home had adopted a pictorial list to aid service users to prepare shopping lists and to carry out the grocery shopping. There were no menus, but service users were able to use this list to help them to choose from some stock items held in the freezer. The care plan for one service user stated that she was diabetic and could have no sugar. An entry within the staff communication book however, stated that her ‘brother had bought her some mini mars bars, they are in the fridge’. Cherrytrees DS0000033114.V272486.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Records indicate that service users’ personal and health care needs are not being adequately met. EVIDENCE: The member of staff on duty was observed to be delivering support in an appropriate and respectful manner. Due to the nature of the service, the majority of service users’ health needs are supported by their families/main carers. One service user, due to exceptional circumstances, was staying at the unit for approximately 4 months. There was evidence that this person was experiencing changes regarding confusion and continence. It was not clear what the service was doing to address these concerns. The resource manager stated that appropriate referrals had been made, but acknowledged that this was not always reflected in records. An October entry in the staff communication book instructed night staff to ‘start waking (the person) up from tonight at about 1am or 2am depending on what time (they) go to bed’. This is of concern as records also indicated that the person was not sleeping or drinking well. In addition, there was no information within the care plan to suggest that there were any issues regarding incontinence at night. Cherrytrees DS0000033114.V272486.R01.S.doc Version 5.0 Page 15 It was previously reported that staff from the adjacent supported living service, were required to support with the administration of medication within the respite unit. This was because the medication policy required two staff to be able to administer medication, and there were not always two staff on duty within the respite unit. This arrangement was still in place at the time of this inspection. In addition, agency staff had not been trained to administer medication, and were still providing a significant amount of support to the unit on a weekly basis. An operations manager had developed a clear and comprehensive draft policy specific to the respite service which set out that there was an ‘ongoing dialogue between Operations Managers and Agency Managers about the need for agency staff to receive basic medication administration training’, and that ‘agency staff who are requested to administer medications will also be subjected to Beds County Council medication training and a pharmacy session’. By the time of writing, the responsible individual for this service, Val Leggatt, had also confirmed that a number of BCC permanent staff were due to start a 21-week distant learning course entitled ‘The Certificate for Safe Handling of Medications’. It was said that in the first instance, permanent staff would support respite medication training, and that there were plans for the agency, Paveys, to use the same training for their staff. Eventually, it is the intention that all respite staff will be trained. There was limited information within service users’ care plans to explain the purpose and possible side effects of each person’s prescribed medication. A ‘sudden death’ procedure, relating to a similar respite service, was on display within the office. Otherwise, this standard was not assessed on this occasion. Cherrytrees DS0000033114.V272486.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22. The home has a satisfactory complaints system. EVIDENCE: The home’s Service User Contract/Terms and Conditions document contained information on how to make a complaint. In addition, a user-friendly version had been developed, and was on display in the entrance hall. The written version of the procedure did not include information on approaching the home manager and/or their direct line manager in the first instance. Since the last inspection of this home, the CSCI had received a call from the parent of one service user, who wanted to share a number of concerns, including a lack of activities, regarding the service. The resource manager was informed at the time, and said that he was making arrangements to visit the parent in question to discuss the matter further. Although there was no evidence within the home’s complaints folder to indicate the outcome of this visit, no further concerns had been received about the service, by the time of writing. Cherrytrees DS0000033114.V272486.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. The environment does not adequately meet the environmental requirements of the National Minimum Standards (NMS) for Younger Adults (18-65), although good efforts have been made to provide a homely place to stay. EVIDENCE: Cherrytrees DS0000033114.V272486.R01.S.doc Version 5.0 Page 18 As previously reported, the respite unit is part of the existing Cherrytrees building which has been ‘made good’ until reprovision of the service takes place. It does not adequately meet the NMS environmental requirements, and would also not meet the needs of all individuals with a physical disability. To this end, the home currently has a condition of registration to reprovide the service by November 2005. At the time of this inspection, there were still no definite plans for reprovision to take place. Therefore, in the interim, the CSCI has agreed that the environment must at a minimum, meet the needs of the service users. The conditions of registration are also in the process of being updated. It was discussed that there were no known plans to put Christmas decorations up for the service users using this facility over the holiday period. An entry made within the staff communication book (3.12.05), indicated that the bed in the largest bedroom had broken. Further examination confirmed this, and that it appeared uncomfortable to use. The member of staff on duty contacted the temporary manager who confirmed that a new bed had been ordered, and was due to arrive on the 14th Dec 05. In the mean time, the manager advised that the base of the bed be padded out using old boxes and blankets. This had not been done however, prior to this inspection. A small area of exposed plasterwork on one of the lounge walls required attention. In addition, information was provided by the responsible individual which set out that a request had been made to the Housing Association for remedial works to address the following: a damaged front gate, an uneven paving slab at the front of the building, fencing off from the adjacent supported living service, and the provision of a notice board in the hallway for service user information. It was not clear if all, or any, of these had been addressed at the time of this inspection. The laundry equipment, which had previously been kept within the first floor Biggleswade A R flat due to limited space within the unit, had been moved into the respite unit, into a small cupboard next to the bathroom. The resource manager had previously stated that this arrangement would be agreed with the local environmental health authority, and the housing association. The unit was noted to be warm, clean, and free from offensive odours. Cherrytrees DS0000033114.V272486.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Staff demonstrated a fair understanding regarding the needs of the service users. However, the high use of agency staff means that only the basic needs of individuals are being met. EVIDENCE: As previously reported, the majority of the care was being provided by a core group of agency workers. On the evening of this inspection, there was one agency member of staff on duty, who had worked in the unit for approximately three months. She had not met one of the two service users previously, but it was noted that she did refer to the person’s care plan, prior to providing actual support. It became apparent that the member of staff only had a limited knowledge of the day-to-day running of the service, and the holistic needs of the service users. Despite this, the person in question was observed to support the two service users in a respectful and appropriate manner. Staff vetting records for permanent staff were still being held centrally and not in the home as required. Staffing profiles were being provided by the agency for agency workers, and these were being held by the home. However, a profile for the member of staff on duty during this inspection, was not found. This included information regarding her qualifications and previous experience. Cherrytrees DS0000033114.V272486.R01.S.doc Version 5.0 Page 20 The CSCI has recently developed some new guidance, which allows for greater flexibility about the storage of staff vetting records, subject to agreement with the local CSCI office. Once an agreement has been reached, certain records may then be held centrally rather than in the care home. A staff training and development plan could not be found on this occasion. The inspector is aware from previous inspections of other BCC services, that a database of staff training is maintained off site however; this information must also be made available within the individual services. The member of staff on duty stated that she was working towards an NVQ 2, and had completed some mandatory training courses. She had not completed a LDAF (Learning Disability Award Framework) induction course. As previously reported a supervision chart within the office indicated that core agency staff did not receive supervision. Feedback from the resource manager indicated that agency staff were receiving supervision from their line manager at the agency. As it is expected that supervision will incorporate a translation of the home’s philosophy and aims for working with individuals, and feedback and monitoring of each staff member’s practice, it is not clear how this arrangement can be sufficient. The member of staff on duty could not remember the last time she had received supervision. In addition, there was also evidence that permanent staff were not receiving supervision at the required intervals. Cherrytrees DS0000033114.V272486.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 There is significant evidence that this service has not been well managed in recent months. As a result, there is limited evidence of progress being made in a number of important areas. EVIDENCE: An application to register a permanent manager for the respite unit remained outstanding. Since the last inspection, there had been two changes in management – both temporary agency workers. An acting manager, Margaret Fajoula, was in place at the time of this inspection however; the CSCI had not been informed of Ms Fajoula’s appointment and experience as is required. She had been working in the unit since 3.10.05. An email was received from Val Leggatt, responsible individual for this service, which provided confirmation that a permanent manager had been appointed, and that vetting checks were being taken up. By the time of writing however, a further update was received to say that the candidate had since declined to take the manager’s position. Cherrytrees DS0000033114.V272486.R01.S.doc Version 5.0 Page 22 It had previously been reported that the inspector had advised, given the numbers of service users (approx 20), and the amount of work required to address ongoing service deficits, that the part time status of the manager should be kept under review. Findings from this inspection have not reduced this concern. There have been previous inspection concerns regarding the apparent ‘blurring’ of the respite service and adjacent supported living service. There was significant evidence at the time of this inspection, that this situation had not been adequately addressed. And, this did not promote the separation of these very different services, or promote the rights and choices of the respective service users. Examples include entries found within the staff communication book such as ‘respite owes buttercup lounge £60 please ASAP. Please find enclosed change from shopping and receipt’, ‘please can you collect (one service user’s) clothes from the main unit laundry’, ‘the main unit wanted to help with food shop’, ‘borrowed bread and milk from main unit’, ‘(two respite services users) will be going to McDonalds this evening. Please check with the main unit what time you leave as you will be teaming up with them’, and ‘I have tried to complete as much work as possible this morning but had to go to the main unit as they were short staffed’. An incident record also stated that ‘I knocked at (one service user’s) room to tell him that he has to have a shower in the main unit’. The resource manager stated that there had been a situation when there had been a difficulty with the hot water, so tenants from the supported living service had been asked if one respite service user could use their shower. There was no evidence of this agreement, and the CSCI had not been informed of the situation at the time. Entries also suggested that there were times when there was insufficient petty cash available within the unit for shopping etc. A number of internal auditing processes were in place however; a quality assurance system that fully met the requirements of this standard was still not in place. Cherrytrees DS0000033114.V272486.R01.S.doc Version 5.0 Page 23 In addition, no reports as required by regulation 26 of the Care Homes Regulations 2001, had been received by the Commission in respect of this home, since the last inspection. A number of entries within the staff communication book were inappropriate. For example, one entry stated that ‘she had a hair wash (thank goodness) and a wash’. Others suggested that service users were ‘put to bed’ rather than making this decision for themselves. A high proportion of entries related to individual services users, and should therefore have been recorded in their individual files. The resource manager stated that these concerns had been addressed with staff, and that weekly checks on communication logs etc would take place. There was evidence of a number of health and safety check systems being in place, i.e. water and fridge temperature charts. No concerns relating to health and safety were noted during this inspection. There was evidence of appropriate insurance to cover the organisations’ assets and liabilities, being in place. And, as previously reported, a part completed business plan for the respite service, was on display. There was evidence that some of this information had been directly copied from another similar service. Cherrytrees DS0000033114.V272486.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 2 1 X 1 Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 X 1 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 1 14 1 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X 1 1 1 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Cherrytrees Score 3 1 2 x Standard No 37 38 39 40 41 42 43 Score 1 X 1 X 2 3 2 DS0000033114.V272486.R01.S.doc Version 5.0 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA9 Regulation 13 Requirement Ensure that individual risk assessments are updated and completed in line with the requirements of NMS 9. (Previous timescale of 31/8/05 not met). Ensure that there is a training and development programme for all staff, which incorporates induction, mandatory and specialist training courses and NVQs as required. (Previous timescales of 31/12/03 and 31/8/05 not met). Ensure that an appropriate application form for a manager is received by CSCI as agreed. (Previous timescales of 31/5/04 and 31/8/05 not met). Revise the current medication policy with regard to administration and the reduced numbers of Timescale for action 28/02/06 2 YA32YA35 18 28/02/06 3 YA37 8 31/03/06 4 YA20 13 and 18 28/02/06 Cherrytrees DS0000033114.V272486.R01.S.doc Version 5.0 Page 26 5 YA40 17 staff on duty within the respite unit. In addition, all staff must receive accredited training with regard to basic knowledge of how medicines are used, how to recognise and deal with problems in use, and the principles behind the home’s policy on medicines handling and records must be arranged. (Previous timescales of 31/8/04 and 31/8/05 not fully met). Ensure that the home’s written policies and procedures are specific to the respite service, and cover all the topics as set out in Appendix 2 of the NMS for Younger Adults. (Previous timescale of 31/8/04 not met. Revised timescale of 31/8/05 given). Not assessed on this occasion. Ensure that a quality assurance and monitoring system is in place for the home, which meets the requirements as set out in standard 39 of the National Minimum Standards for Younger Adults. (Previous timescales of 30/9/04 and 31/8/05 not met). Ensure that staff understand the main aims and values of the home by providing DS0000033114.V272486.R01.S.doc 31/03/06 6 YA39 24 31/03/06 7 YA36 18 31/01/06 Cherrytrees Version 5.0 Page 27 8 YA7YA3YA6 15 9 YA5 5 10 YA14YA13 12 and 16 11 YA19 12 and 13 12 YA34 19 formal supervision to all staff including regular agency members of staff. (Previous timescales of 5/11/04 and 31/8/05 not met). Develop current care plans with the involvement of the service users, to ensure that plans (fully meet the requirements of NMS 6, and) include measurable goals aimed at supporting individuals to maximise their independent living skills. (Previous timescale of 31/8/05 not fully met). Service users must all have an individual written contract or statement of terms and conditions with the home. All service users must have the opportunity to access the local community, and to engage in appropriate activities both in and out of the home. The healthcare needs of service users must be recognised, assessed, and have clear procedures in place to address them. Demonstrate that satisfactory recruitment procedures (for all staff) have been followed. *Please note that from 26/7/04 ‘Schedule 2’ has been updated within the amended Care 28/02/06 28/02/06 31/01/06 31/01/06 31/01/06 Cherrytrees DS0000033114.V272486.R01.S.doc Version 5.0 Page 28 Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004. Also, from November 2005, new CSCI guidance is in place regarding the storage and retention of staff vetting records. Arrangements should now be made in line with this guidance. Visits as specified by Regulation 26 of the Care Homes Regulations 2001, must be carried out on a monthly basis. Copies of the reports must then be forwarded to the CSCI. Service users must know that information about them is handled appropriately, and that their confidences are kept. 13 YA39 24 31/01/06 14 YA2YA43YA1YA41YA10 17 28/02/06 15 YA41 CSA s28 (1) In addition, records should be maintained as set out in regulation 17 of The Care Homes Regulations 2001 that are specific to the service being provided at Cherrytrees respite service. A certificate of 31/12/05 registration issued under this part of the act (CSA), in respect of the home, must be kept affixed in a conspicuous place in the Version 5.0 Page 29 Cherrytrees DS0000033114.V272486.R01.S.doc establishment at all times. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA37YA33 Good Practice Recommendations Consideration should be given to increasing the current allocated hours (specifically dedicated to the respite service), for the manager, to reflect the needs of this diverse and expanding service.(This is a recommendation from the 31/5/05 report). Any outstanding environmental matters referred to in the ‘environment’ section of this report, should now be addressed. 2 YA24 Cherrytrees DS0000033114.V272486.R01.S.doc Version 5.0 Page 30 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cherrytrees DS0000033114.V272486.R01.S.doc Version 5.0 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!